Squamous Papilloma in the Oral Cavity: Case Presentation and Review of the Literature

Journal of Dental Health Oral Disorders & Therapy

Case Report Open Access Squamous papilloma in the oral cavity: case presentation and review of the literature

Abstract Volume 9 Issue 4 - 2018 Oral Squamous Papilloma is the most common benign tumor that can be found in Juan Martín Pesántez Alvarado,1 Valeria the oral cavity, the main etiological factor is Human Papilloma Virus (HPV), the Paulina Romero Rodríguez,2 Milton Fabricio route of transmission of this virus is through direct contact, despite being a lesion 3 with benign characteristics, it has been observed in recent years that HPV infection Lafebre Carrasco, Víctor Rafael Vazquez 4 is directly associated with the presence of Squamous Cell Carcinoma in the oral Ramos, Julieta del Carmen Reinoso cavity, becoming a factor of importance that must be addressed by the different health Carrasco5 services worldwide. We present the case of a 63-year-old male patient who attended Department of Pathology and Oral Surgery, University of the Dental Clinic of the Faculty of Dentistry of the Pontificia Universidad Javeriana Cuenca, Ecuador Bogotá - Colombia. Through the intraoral examination, a papillary lesion on the soft Department of Dental and Maxillofacial Imaging, University of palate was found. An excisional biopsy was performed and the diagnosis is confirmed Cuenca, Ecuador by histopathological examination. Department of Periodontics, University of Cuenca, Ecuador Department of Pathology and Oral Surgery, Quetzalcóatl Keywords: papilloma, HPV, oral cavity, diagnosis Irapuato University, Mexico Department of Biochemistry, Master of Toxicology, University of Cuenca, Ecuador

Correspondence: Milton Fabricio Lafebre Carrasco, Department of Periodontics, University of Cuenca, Ecuador, Email [email protected]

Received: May 30, 2018 | Published: July 03, 2018

Introduction after the infection of the basal layer and a variable incubation time, the replication and assembly of virions occurs in conjunction with Squamous papilloma is the most common benign epithelial tumor the squamous cell differentiation. When the infections are in low of the oral mucosa, it is identified as an exophytic proliferation giving layers, the number of viral copies per cell is also too low to transmit 1 rise to papillary lesions with finger-like projections. It constitutes the disease, in subclinical infections, viral replication of DNA and 2.5% of the lesions of the entire oral cavity, larynx, bronchial tree, transcription are active, the observable lesions contain the active 2 esophagus, bladder, anus and genital tract. The main etiologic factor virus, these are usually exophytic, flat, papillomatous or verruciform, of these lesions is the Human Papillomavirus (HPV), which comprises endophytic or less observable.6 In the case of lesions located in different types within the Papillomaviridae family, they do not contain the uvula or in places close to it, patients usually have difficulty any envelope, their diameter is 55nm, and their capsule is icosahedral swallowing food, therefore surgical excision should be performed as 3 (72 capsomere protein). Most HPVs that infect mucous membranes soon as possible.7 The aim of this article is to review the literature and belong to the group of alpha-papillomaviruses, are considered high present the case of a squamous papilloma of the soft palate. risk (16 and 18) represent approximately 70% of conditions of higher degree of malignant transformation while those of low risk (6 and Case presentation 11) are the most common types associated with benign lesions.3 In the United States, during the years 2009 to 2010, a cross-sectional A 63-year-old male patient resident of the city of Bogotá, who study was conducted in the civil population of the patients and it was attends the dental clinics of the Faculty of Dentistry of the Pontificia reported that the prevalence rate of oral HPV infection in men and Universidad Javeriana, was referred to the oral pathology clinic. The women between 14 and 69 years of age was 6.9% and of HPV 16 patient with a history of Diabetes Mellitus type II diagnosed about 1 was identified in 1%. A higher rate of HPV was identified inmen year ago controlled with Metformin 800mg twice a day, smoked 20 than in women, and between 30 and 34 years and between 60 and 64 cigarettes a day for about 40 years. At the time of clinical examination years.4 According to the site of infection, HPVs that infect the oral a vegetative lesion with a pedunculated base of approximately 8mm cavity are considered mucocutaneous. The literature associates HPV in diameter, whitish in color was observed at the soft palate level with the appearance of anogenital warts, cancer of the oropharynx, lateral to the base of the uvula, the patient does not know the time of dysplasia and cervical cancer, at least 40 types of HPV can infect the evolution. 4 skin, genitals and mucous membranes. Its transmission is diverse: it According to the clinical examination and the data obtained during can occur in the perinatal period and later in life, by sexual contact the anamnesis, the following presumptive diagnosis was obtained: and autoinoculation, although some authors also suggest a possible squamous papilloma. As a treatment, the following procedure is transmission by saliva, oral sex has been established as the main performed: excisional biopsy of a vegetative lesion of the soft 5 method of transmission of HPV in mouth. The lesions are limited palate. After asepsis and antisepsis, the anesthetic (lidocaine 2% specifically to the squamous epithelium of the mucous membranes, with epinephrine 1: 80000) is applied at the perilesional level, the

Submit Manuscript | http://medcraveonline.com J Dent Health Oral Disord Ther. 2018;9(4):257‒260. 257 © 2018 Alvarado et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially. Copyright: Squamous papilloma in the oral cavity: case presentation and review of the literature ©2018 Alvarado et al. 258

incision is made with electrocautery around the lesion and the sample is obtained. Subsequently, the sample of the lesion is placed in 10% formalin, labeled and sent for histopathological study.

Discussion The squamous papilloma located in the oral cavity is a frequent, asymptomatic lesion, which is usually detected through the clinical examination by the dentist. Depending on the degree of keratinization, the color of the surface of the lesion varies between red, pink or white, the most common places are the palate and the tongue, the age of presentation ranges from 20 to 50 years, with the lesions being mostly unique. Devi et al.,1 mention that in a sample of 464 squamous papillomas of the oral cavity, 34.3% of these lesions were located in the palatal complex (hard palate, soft or uvula), the majority being benign and asymptomatic.7 Benign squamous papilloma is associated with low risk types of HPV 6 and 11,8 affecting patients of all ages, but more often diagnosed from the second to fourth decade of life,8 which suggests that the appearance of these lesions is more frequent in people with active sexual life. However, some studies have not been able to demonstrate a correlation between the practice of oral sex and HPV infection, suggesting also that they operate non-sexual transmission mechanisms. Significant levels of HPV infection have been observed in the mouth of children aged 1 year and younger than 19 years of age, therefore studies support the vertical transmission of HPV to the oral cavity of the mother to the baby, in addition to other modes of transmission that include autoinoculation, although the lack of concordance between the HPV genotype in the oral and anal sites indicates that this is a rare modality.8 The viral life cycle begins when the virus enters through microabrasion to the basal layer, joining the Histopathological examination report surface receptors of the basal layer (Integrin 6, Heparan Sulfate and Proliferation of stratified keratinized squamous epithelium, CD69); the virions may or may not be incorporated into the nucleus of arranged in finger-like projections with fibrovascular connective the cells, however the viral proteins E1, E2, E6, E7 are expressed at low tissue cores, the superficial layer of keratin is denser in lesions with levels; after cell division, the infected cells migrate to the suprabasal a more white clinical appearance. The koilocytes are clear epithelial zone and begin to differentiate by activating a transcriptional cascade 5 cells with small pyknotic nuclei. coordinated with the viral genome. HPVs are characterized by a special tropism for squamous epithelial cells and keratinocytes. The synthesis of viral DNA and the expression of viral genes (especially for those that encode capsid proteins) are related to the level of differentiation of keratinocytes. The normal viral replication cycle is a highly regulated process, depending both on some viral proteins encoded by the viral genome and the degree of differentiation of the infected cell; the infection usually begins in the basal and para-basal cells of the squamous epithelium. Changes in keratinocytes from the basal layer to the surface of the epithelium provide a suitable micro- environment for productive cellular replication.6 Histologically, HPV infection can be observed as an acanthotic, dyskeratotic lesion with keratinocyte multinucleation and koilocytosis. Postoperative control after 8 days. These histological features occur when infection becomes productive,

Citation: Pesántez J, Romero V, Lafebre F, et al. Squamous papilloma in the oral cavity: case presentation and review of the literature. J Dent Health Oral Disord Ther. 2018;9(4):257‒260. DOI: 10.15406/jdhodt.2018.09.00387 Copyright: Squamous papilloma in the oral cavity: case presentation and review of the literature ©2018 Alvarado et al. 259

viral genes are sequentially expressed from early genes to late genes, other less common types of HPV that are also the cause of this cancer. followed by squamous epithelial differentiation, from basal and One of the vaccines also protects against types 6 and 11, which cause parabasal cells, where the early portions of the genome are more anogenital warts. active and proceed to the upper layers of the epithelium (intermediate The bivalent vaccine called (Cervarix) offers protection against and superficial), together with the formation of the complete virion HPV types 16 and 18, the accepted indications for the bivalent vaccine (i.e, the infected viral particle). The classic viral cytopathic effects that are only cervical cancer and its precursors. may appear: koilocytosis in particular, is considered as the obvious expression of a viral cytopathic effect. The koilocytic cell shows a The quadrivalent vaccine (Gardasil) includes protection against thicker cytoplasm at the level of the inner wall of the membrane and HPV 6 and 11 because genital warts are benign mucosal lesions of the morphologically crashed atypical cell nucleus. Histologically, HPV mucosa caused by the human papillomavirus (HPV), most commonly infection can be observed as an acanthotic, dyskeratotic lesion with types 6 and 11. These lesions are part of one of the most common viral keratinocyte multinucleation and coilocytosis.6 sexually transmitted infections and are very common in people with more than 10 sexual partners throughout their life or in sexual partners, The most common differential diagnosis suggested was that of where at least one had genital warts, the use is limited to cancers of a condyloma. This lesion can be mistakenly considered a papilloma the vulva , the vagina and the anus and their precursors.14 Regarding because the macroscopic aspect can also show a surface similar to the oral cavity, until 2015, only 9 cases have been reported in which a cauliflower. These entities can be differentiated macroscopically, the quadrivalent vaccine was applied in patients with oral lesions microscopically and immunologically. The number of elements, associated with HPV, with encouraging results in short-term patients, the size of the lesion, the stem, the location and the color can help however in patients with immune alterations, the effectiveness of the distinguish them. Other similar entities include verruca vulgaris, vaccine on present lesions decreases considerably.15 Despite this, in verruciform xanthoma, verrucous carcinoma, among others.2 The the preventive field, in the few studies that are being carried out to treatment of choice of squamous papilloma is surgical excision, there date, a reduction in the prevalence of oral HPV 16 - 18 lesions is are various forms of surgical treatment, one of which is cryosurgery, observed among vaccinated women, however, are still questioned which is defined as the surgical technique based on the destruction of because the indication of the vaccine is based on the epidemiology of affected or unwanted cells and tissues, through the action of the cooling HPV in the cervix, so it is necessary to carry out studies that provide elements at subzero temperature, this treatment has advantages because definitive evidence for the use of the vaccine as a method preventive there is no bleeding, minimum need for anesthesia, the postoperative in the development of oral cancer.14 period is faster and less traumatic.9 The form of replication of HPV is different depending on the type of lesions; in benign lesions, the HPV Conclusion genome is found in an extrachromosomal episomal (plasmid) form, whereas in malignant lesions, viral DNA is integrated into the host The squamous papilloma is a common benign lesion among genome.10 Regarding the association of HPV with the development patients attending the dental practice, however according to recent of cancer in the oral cavity, it is manifested: the integration of the studies, HPV is closely associated with the development of oral viral genome in the host cell is a very rare event, affecting the host squamous cell carcinoma, therefore the dentist is under an obligation chromosomes in fragile sites, after the transformation to carcinogens to examine the oral cavity of patients looking for lesions that may the neoplastic process progresses rapidly. The integration of HPV in indicate neoplastic process caused by HPV, since in the early stages, the host genome induces the increase of the expression of E6 and E7 the response to treatment confers a favorable prognosis and inform proteins, since the integration results, produces the interruption of the patients about the risk factors for developing this disease and its E2 gene of HPV, which is a negative regulator of the transcription preventive methods. of proteins E6 and E7. High-risk HPV E6 and E7 oncoproteins can independently induce genomic instability in normal human cells.11 As Acknowledgements expressed above, the incidence rates of base of tongue cancer and None. tonsil has increased gradually, according to data from the National Cancer Institute, Epidemiology in the United States, from 1973 Conflict of interest to 2001 it was documented that base of tongue cancer and palatine tonsils increased between 2 to 4% annually, these two locations being The author declares that there is no conflict of interest. the most frequent.12 References HPV seems to have tropism by Waldeyer’s lymphoepithelial 1. Frigerio M, Martinelli-Kläy CP, Lombardi T. Clinical, histopathological ring, in lingual and palatine tonsils, in these areas there are deep and immunohistochemical study of oral squamous papillomas. 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